From the Guidelines
Aortic valve replacement carries significant risks, including death, stroke, bleeding, infection, and heart rhythm abnormalities, with the risk profile varying based on patient age, comorbidities, valve type, and procedure urgency. The risks associated with aortic valve replacement (AVR) can be substantial, including mortality rates of 1-3% for surgical replacement and slightly lower for transcatheter approaches 1. Other significant risks include stroke (1-5%), bleeding requiring transfusion, infection, and heart rhythm abnormalities, particularly atrial fibrillation.
Risks Specific to Surgical Replacement
Surgical AVR carries additional risks such as chest wound complications, prolonged ventilation, and a longer recovery time. In contrast, transcatheter valve replacement has its unique set of risks, including vascular complications, paravalvular leak, and a potential need for a permanent pacemaker, which can occur in 10-20% of cases 1.
Long-term Risks
Long-term risks for all valve replacements include valve deterioration requiring reoperation, especially with bioprosthetic valves, endocarditis, and for mechanical valves, bleeding complications from required lifelong anticoagulation with warfarin, targeting an INR of 2.0-3.0 1. Patients with mechanical valves need consistent anticoagulation monitoring and face significant risks if anticoagulation is interrupted.
Factors Influencing Risk Profile
The risk profile for AVR varies significantly based on patient age, comorbidities (especially lung disease, kidney disease, and previous heart surgery), the type of valve selected, and whether the procedure is elective or an emergency 1. Despite these risks, successful valve replacement typically improves symptoms and extends life expectancy for patients with severe aortic valve disease, as indicated by guidelines from the American College of Cardiology/American Heart Association 1.
Guideline Recommendations
Guidelines recommend AVR for symptomatic patients with severe aortic stenosis (AS) and high risk for surgical AVR, depending on patient-specific procedural risks, values, and preferences, with a Class I, Level of Evidence A recommendation for TAVR in such cases 1. The choice between surgical AVR and TAVR should be made by a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals 1.
From the Research
Risks of Aortic Valve Replacement
The risks associated with aortic valve replacement can be significant, and it's essential to understand these risks to make informed decisions about treatment. Some of the key risks include:
- Bleeding complications: Studies have shown that bleeding complications are a common risk after surgical aortic valve replacement (SAVR) 2, 3.
- Stroke: The risk of stroke is also a concern, although studies have shown that the incidence of stroke is similar between reoperative SAVR and primary isolated SAVR 4.
- Death: Hospital mortality after reoperative SAVR has decreased over time, but it is still a risk, with a reported rate of 1.3% in one study 4.
- Renal dialysis: The need for new renal dialysis is a potential risk, although one study found that the incidence was similar between reoperative SAVR and primary isolated SAVR 4.
- Blood transfusion: Blood transfusion is a common complication after SAVR, with one study reporting a rate of 67% after reoperative SAVR 4.
- Reoperations for bleeding/tamponade: Reoperations for bleeding or tamponade are also a risk, with one study reporting a rate of 6.4% after reoperative SAVR 4.
Comparison of Risks between SAVR and TAVR
Studies have compared the risks of SAVR and transcatheter aortic valve replacement (TAVR), with some key findings including:
- Bleeding complications: TAVR has been shown to have a lower rate of bleeding complications compared to SAVR 2.
- Mortality: The risk of mortality is similar between SAVR and TAVR, although one study found that bleeding complications after SAVR had a greater impact on prognosis than after TAVR 2.
- Vascular complications: TAVR has been shown to have a lower rate of major vascular complications compared to SAVR 2.
Patient-Specific Risks
Patient-specific factors can also influence the risks associated with aortic valve replacement, including:
- Age: Older patients may be at higher risk for complications after SAVR, although one study found that the need for transfusion and incidence of atrial fibrillation were lower in younger patients 5.
- Comorbidities: Patients with certain comorbidities, such as end-stage renal disease or severe lung disease, may be at higher risk for complications after SAVR.
- Valve type: The type of valve used for replacement can also influence the risks, with bioprosthetic valves generally considered to have a lower risk of complications compared to mechanical valves.